A nurse is assessing a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?

"l need to walk slowly as I lose my balance often."

"l don't go out much because of the pain in my legs."

"It makes me sad that I can't keep up with my grandchildren."

"l have a small-healed area on my spine that is painful."

Answer and Explanation

The Correct Answer is A

A. "I need to walk slowly as I lose my balance often": This statement indicates a potential safety concern related to balance issues while walking. Loss of balance can increase the risk of falls, especially in individuals with peripheral artery disease (PAD) who may already have compromised circulation and reduced sensation in their legs. The nurse should report this statement to the provider for further evaluation and intervention to prevent falls and promote safety.

B. "I don't go out much because of the pain in my legs" : While this statement suggests that the client experiences pain in their legs, it does not directly indicate a safety concern that requires immediate reporting to the provider. Pain management strategies may be discussed with the provider to address this issue.

C. "It makes me sad that I can't keep up with my grandchildren" : While this statement reflects emotional distress related to the client's inability to participate fully in activities with their grandchildren, it does not indicate a specific safety concern that requires reporting to the provider. However, addressing the client's emotional well-being is important for overall holistic care.

D. "I have a small-healed area on my spine that is painful" : This statement describes a painful area on the client's spine but does not directly relate to potential safety concerns associated with PAD. The nurse may further assess this issue and include it in the client's overall assessment, but it does not require immediate reporting to the provider for safety concerns related to PAD.

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Correct Answer is B

Explanation

A. Muscular aches in the leg: Muscular aches in the leg are not typically indicative of an impending cardiac arrest. While leg pain or cramping can be associated with peripheral vascular disease or venous insufficiency, they are not specific signs of cardiac arrest.

B. Profound fatigue: Profound fatigue can be a warning sign of an impending cardiac arrest. Fatigue or weakness can result from inadequate blood flow to the heart muscle, which may occur prior to a cardiac event. Additionally, systemic effects of cardiovascular compromise can lead to generalized weakness and fatigue.

C. Severe headache: While severe headache can be associated with conditions such as hypertension or intracranial bleeding, it is not a typical manifestation of an impending cardiac arrest. Headaches may occur as a result of stress or anxiety related to the cardiac event, but they are not a direct warning sign of impending cardiac arrest.

D. Ringing in the ears: Ringing in the ears, also known as tinnitus, is not typically associated with an impending cardiac arrest. Tinnitus can result from various factors such as noise exposure, ear infections, or certain medications, but it is not considered a warning sign of impending cardiac arrest.

A. The client has metabolic alkalosis and warm extremities B. The client develops bradycardia and bradypnea C. The client has hypotension and is confused D. The client has hypertension and anuria

Correct Answer is C

Explanation

A. The client has metabolic alkalosis and warm extremities: Metabolic alkalosis and warm extremities are not typically indicative of postoperative shock. Metabolic alkalosis may be caused by excessive vomiting or prolonged gastric suctioning, but it is not a hallmark sign of shock. Warm extremities may suggest adequate peripheral perfusion rather than impaired perfusion seen in shock.

B. The client develops bradycardia and bradypnea: Bradycardia (slow heart rate) and bradypnea (slow respiratory rate) may occur as compensatory mechanisms in certain types of shock, such as neurogenic shock. However, they are not specific indicators of postoperative shock. Tachycardia (rapid heart rate) and tachypnea (rapid respiratory rate) are more common findings in most types of shock, including postoperative shock.

C. The client has hypotension and is confused: Hypotension (low blood pressure) and confusion are classic signs of shock, including postoperative shock. Hypotension indicates inadequate perfusion of vital organs, while confusion may result from cerebral hypoperfusion. Altered mental status, such as confusion, is a significant neurological manifestation of shock.

D. The client has hypertension and anuria: Hypertension (high blood pressure) and anuria (decreased urine output) are not typical manifestations of postoperative shock. Hypertension may occur in certain conditions that can lead to shock, such as septic shock, during the compensatory phase. However, it is not a primary sign of shock. Anuria may occur in cases of severe hypovolemic shock but is not specific to postoperative shock.

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A nurse is assessing a client who has peripheral artery disease for potential safety concerns. Which of the following client statements should the nurse report to the provider?

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